Eye E&M Codes Subject to New Medicare Coding Edit

On claims processed April 7, 2014, or later, Medicare Correct Coding Initiative (CCI) edits will not recognize use of modifier 59 with the ophthalmological evaluation and management (E&M) codes 92012 and 92014.

The Centers for Medicare & Medicaid Services (CMS) updates CCI edits quarterly; you should check out the changes each quarter for those that may apply to your specialty. You can view the edits in the physician files (these are large, zipped files) located under "Related Links" at the bottom of the CMS CCI edits webpage. This CMS guide (PDF) explains how to use Medicare's CCI tools.

The Eye Codes

As is already the case with E&M codes 99201-99499, the eye codes 92012 and 92014 will become subject to CCI edits with regard to modifier 59. As such, if you submit a claim E&M code 92012 (intermediate) or 92014 (comprehensive) with modifier 59, Novitas Solutions, the Medicare payer for Texas, will process the claim as though the modifier were not present.

Modifier 59 identifies procedures or services that are not normally reported together but are appropriate under the circumstances. You should not use it with E&M codes. When appropriate, report modifier 25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure of another service) with codes 92012 or 92014 in lieu of modifier 59. Documentation must meet and support the definition of the modifier billed.

Although modifier 59 is the most commonly reported modifier that affects CCI processing, it is often used incorrectly. This article (PDF) from CMS explains how to use the modifier and gives a variety of examples.

If you have questions about billing and coding or payer policies, contact the reimbursement specialists at paymentadvocacy@texmed.org for help, or call the TMA Knowledge Center at (800) 880-7955. TMA members can use the TMA Hassle Factor Log to help resolve insurance-related problems.